Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Friday, September 12, 2008

My Experience With Government-Run Healthcare

I have seen government-run healthcare first-hand.

Many others have, too, for many a soldier, sailor, Marine or airman, (and even a Congressman or two) have their lives to thank because of that system. But in this time of a new presidential election and the talk of such a system for the nation, I cannot help but reflect on my experiences at an officer in the United States Navy Medical Corps.

My reasons for joining the military at the time were not out of financial need, but rather my desire to achieve financial independence from my family. I did not want my father (the family breadwinner at the time) to pay for my medical education. It was my personal separation from my family as a young adult, and the pride in being able to stand on my own two feet without their financial support, that drove me to seek a military scholarship to pay my way through medical school. I was finishing engineering school at Duke University and a Naval recruiter came to our campus. Since my brother was on a ROTC scholarship to pay for his college education, I learned about their programs for supporting myself through medical school and the service commitments required. I eventually applied to the Health Professions Scholarship Program after receiving my first acceptance to a US medical school and was accepted.

But first, I had to have a recruitment physical. It occurred at a recruiting station somewhere in North Carolina (for I was a Duke at the time).

Walking in clueless, I was asked to sit in a room with what seemed like a sea of other applicants from all walks of life. We were carefully instructed on how to write or names within the boxes on the physical form, where it asked for “Sex” to enter “W” for woman or “M” for male and not “Yes” or No,” and to not complete any portion of the application on side two, lest they be keel-hulled for not waiting for the intellectually less-inclined. Finally, alter completing the medical history forms, we were off to the physical portion. But the physical was not to be performed privately and personally – no, that would take too much time – rather en masse. Men were separated from women, and gradually removed more and more of their clothing. Spines were checked for scoliosis, feet were checked for pes planus (flat feet), a cursory listen to the lungs for wheezes, and finally and most memorably, men were asked to turn around, drop their underwear, spread our cheeks while the doctor examined them for hemorrhoids. Oh baby. What a way to say “Welcome to the Navy!” All I could think was: “Is this what I’ll be doing?”

After surviving that memorable experience, I received my scholarship: full tuition to medical school, reimbursement for books and required medical equipment, and what seemed like a fortune to me at the time: $500 per month. The memory of that fateful exam day faded quickly.

After medical school, I received my first set of orders to report to the National Naval Medical Center in Bethesda, MD. At the time, it was one of the most impressive hospitals I had seen – the pride of Navy Medicine. I was honored to be there. It was a new, squeaky-clean, beautifully-constructed facility attached to the original towering monolithic original hospital whose site was chosen by President Roosevelt but later had proven too impractical to care for patients due its paucity of elevators. Bethesda stood in stark contrast to the recruiting center I initially thought represented Navy medicine.

My colleagues, fellow lieutenants, were equally impressive, hailing from private medical schools across the country. Most were smart, bright, eager to excel, and a only a very rare few, like any workplace, weren’t exactly the sharpest knives on the shelf. My experience with military medicine was some of the best of my life and the friends and colleagues I grew to know, some of the best of my carrier.

When I started, there were 30 patients per medicine ward team and four teams managing patients. Each medicine team consisted of a resident and four interns. It was a hotbed of Naval referrals being the benefactor of military healthcare after the Vietnam war. We saw everything, since we treated not only active duty members and their families, but retirees and their families, too - many from far-away destinations. I will always remember those late-night Medivac admissions!

Working there on occassion, we also saw things others rarely get to see: big blue curtains going up around the hospital. This was when the biggest patients of all would visit, usually for their annual physicals: the President or Vice President of the United States. Needless to say this was somewhat disruptive to have the President, like the Wizard of Oz, somewhere behind a curtain as he was escorted from appointment to appointment, but those of us in the trenches usually went on our merry way without much thought since there was so much work to be done for others.

There was a clear hierarchy of care on several levels in the military: the first by rank, the second by active duty status. Admirals and Congressman were always escorted and given priority for appointments, then active duty, then active duty member's families, then retirees, then those eligible for disability benefits: boarded out with over 30% disability. There was never a question of how to ration health services... ever... for each person had an ID card, each person had a rank, and each person had their duty status.

When caring for the patients lucky enough to acquire appointments, at first we never thought about the cost of healthcare for our military members. I would order a CT or MRI if my patient needed it, no questions asked. The equipment was always state-of-the-art and our basic military medical training was comparable to any in the US. Training for subspecialties was routinely farmed out to the private sector and residents left for a few years, returning from many prestigious programs to share their knowledge and experience with us upon their return. It was medical utopia.

But after the Vietnam war ended and the glut of excessive military healthcare facilities made its presence known on Capital Hill, cost-cutting was rampant as the military tried to shore in its costs through the Base Realignment and Closure (BRAC) initiative. Our medical ward services shrunk over my 10 years at Bethesda from four to one, and the patient census was bearly adequate to satisfy our residency credentialing requirements. I can remember vividly our catheterization laboratory struggling to keep our expenses to $1.4 million dollars annually as we tried to perform required angiography and medical device implants (yep, pacemakers and defibrillators, too) to our members. Slowly, insidiously, patient volumes plummeted as not only because of base closing, but because active duty members were increasingly shunted to the private sector to offload the financial burden to another government pot of money: Tricare – the military's health care insurance system. This system has degenerated into a poor substitute for our military members, as others have recently commented. Regretably, the maintenance of the grounds also suffered as cuts continued - Walter Reed was especially hard hit.

It was a challenging time. I saw many a colleague leave the service for greener pastures in the lucrative private sector. I, too, was eventually lured away because the military, even with their "perks" and tax breaks, just could not remain financially competitive. I left after 13 and a half years, but remained with the Reserves, in part because I enjoyed the camaraderie, but more, because I did not want to throw away the potential for an eventual retirement pension. Family responsibilities have a way of making you think that way.

So I am left to wonder, as the thought of a single government run healthcare is considered by many, should we not learn from our prior experiences? Medicare is about to go broke, the military healthcare system, while constantly shifting as Congress approves or disapproves its budgets, has seen a dwindling of its ability to care for those most deserving due to costs. Rationing has helped the military cope with their limits, but for the military, rationing is simple since rank and duty status are so obvious. What would happen if a similar healthcare system was thrust upon the greater civilian population? Where will people be shunted in our new system when we realize it is too expensive or we have too few doctors to provide the care? In short, how will our "rank" be determined? Can we really expect that universal healthcare will not exact a toll on each and every one of us?

Of course it will. And perhaps it should. But without discussing ways to limit costs, earmarks, grotesque unlimited spending for facilities, lack of transparency of real costs to our system, and ways to shore up the numbers of doctors sure to abandon the profession as the inevitable cuts inherent to such a system are enacted, we're bound to see the same problems as the systems that have come before.

4 comments:

Good points Sir. Tricare is even with various levels like Prime and remote (there are more). I recently retired and honestly cannot complain about the care I get but, I am healthy! :) I have Tricare Prime, it is available where I live but others in other locations are not as lucky.

"Here we have a bankrupt government run health care system trying to convince a nation it is time to put out their old folks for the benefit of all, and here in the US the liberals want to let babies die so they won’t be a burden."health care plans will force people into government-run health care plans full of bureaucracy.

Thank you for serving. My husband, and my family count on people like you for our healthcare. We feel blessed to have low cost healthcare because we know so many who make what we do and can't afford it.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.